National Health Service (England)

The National Health Service (NHS) is the name of the publicly funded healthcare systems in England (though the term is also used to refer to the four national health services in the UK, collectively). The NHS provides healthcare to anyone normally resident in the United Kingdom with most services free at the point of use for the patient though there are charges associated with eye tests, dental care, prescriptions, and many aspects of personal care.

The NHS provides the majority of healthcare in England, including primary care, in-patient care, long-term healthcare, ophthalmology and dentistry. The National Health Service Act 1946 came into effect on 5 July 1948. Private health care has continued parallel to the NHS, paid for largely by private insurance, but it is used by less than 8% of the population, and generally as a top-up to NHS services. Recently the private sector has been increasingly used to increase NHS capacity despite a large proportion of the public opposing such involvement according to one survey by the BMA[1].

Contents

In the aftermath of World War II, Clement Attlee's Labour government created the NHS as part of the "cradle to grave" welfare-state reforms, based on the proposals of the Beveridge Report, commissioned by Arthur Greenwood, Labour's Deputy Leader and wartime Cabinet Minister with responsibility for post-war reconstruction and prepared in 1942 by the economist and social reformer William Beveridge. The idea was that if Britain could work towards full employment and spend huge sums of money during the wartime effort, then in a time of peace equitable measures of social solidarity and financial resources could be redirected towards fostering public goods. Aneurin Bevan, the newly appointed Secretary of State for Health, was given the task of introducing the National Health Service.

Healthcare in the UK prior to the war had been a patchwork quilt of private, municipal and charity schemes though half of Scotland's land mass was covered by public provision (the Highlands and Islands Medical Service). Bevan now decided that the way forward was a national system rather than a system operated by regional authorities to prevent inequalities between different regions. He proposed that each resident would be signed up to a specific General Practice (GP) as the point of entry into the system. From that point on, any resident of the UK would have access to any kind of treatment they needed without having to face the embarrassment of being unable to pay for it.

Doctors were initially opposed to Bevan's plan, primarily on the grounds that it reduced their level of independence. Bevan had to get them onside, as, without doctors, there would be no health service. Being a shrewd political operator, Bevan managed to push through the radical health care reform measure by dividing and cajoling the opposition, as well as by offering lucrative payment structures for consultants. On this subject he stated, "I stuffed their mouths with gold". On July 5, 1948, at the Park Hospital (now known as Trafford General Hospital) in Manchester, Bevan unveiled the National Health Service and stated, "We now have the moral leadership of the world".

The cost of the new NHS soon took its toll on government finances. On 21st April 1951 the Chancellor of the Exchequer, Hugh Gaitskell, proposed that there should be a one shilling (5p) prescription charge together with new charges for half the cost of dentures and spectacles. Bevan resigned from the Cabinet in protest. This led to a split in the party that contributed to the electoral defeat of the Labour government in 1951. The one shilling prescription charge was introduced in 1952 together with a £1 flat rate fee for ordinary dental treatment. Prescription charges were abolished in 1965. Prescriptions remained free until June 1968 when the charges were reintroduced.

Dr A. J. Cronin's highly controversial novel, The Citadel, published in 1937, had fomented extensive dialogue about the severe inadequacies of health care. The author's innovative ideas were not only essential to the conception of the NHS, but in fact, his best-selling novels are even said to have greatly contributed to the Labour Party's victory in 1945.[4] Millions of citizens had been unable to afford the privatized system and were disenfranchised from access to health care before the NHS. Now, every single person has access to quality health care that is financed through progressive taxation, that is, from each according to his ability to pay, to each according to his needs as a patient.

The NHS is committed to providing quality care that meets the needs of everyone, is free at the point of need, and is based on a patient's clinical need, not their ability to pay. The NHS will not exclude people because of their health status or ability to pay.

The main aims are:

To provide a universal service for all based on clinical need, not ability to pay

To provide a comprehensive range of services

To shape its services around the needs and preferences of individual patients, their families and their carers

To respond to the different needs of different populations

To work continuously to improve the quality of services and to minimize errors

To support and value its staff

To use public funds for healthcare devoted solely to NHS patients

To work with others to ensure a seamless service for patients

To help to keep people healthy and work to reduce health inequalities

To respect the confidentiality of individual patients and provide open access to information about services, treatment and performance

The NHS in England is controlled by the UK government through the Department of Health (DH), which takes political responsibility for the service. The DH controls ten Strategic Health Authorities (SHAs), which oversee all NHS operations, particularly the Primary Care Trusts, in their area. These are coterminous the nine Government Office Regions for the most part, with the South East region split into South East Coast and South Central SHAs.

NHS primary care trusts (PCTs), which administer primary care and public health. On 1 October 2006 the number of PCTs was reduced from 303 to 152 in an attempt to bring services closer together and cut costs. These oversee 29,000 GPs and 18,000 NHS dentists. In addition, they commission acute services from other NHS Trusts and the private sector, provide primary care in their locations, and oversee such matters as primary and secondary prevention, vaccination administration and control of epidemics. PCTs control 80 per cent of the total NHS budget

A feature of the NHS, distinguishing it from other public healthcare systems in Continental Europe, is that not only does it pay directly for health expenses, it also employs a large number of staff that provide them. In particular, nearly all hospital doctors and nurses in England are employed by the NHS and work in NHS-run hospitals.

In contrast General Practitioners, dentists, optometrists (opticians) and other providers of local healthcare, are almost all self-employed, and contract their services back to the NHS. They may operate in partnership with other professionals, own and operate their own surgeries and clinics, and employ their own staff, including other doctors etc. However, the NHS does sometimes provide centrally employed healthcare professionals and facilities in areas where there is insufficient provision by self-employed professionals.

It should be noted that NHS workforce figures provided by the Department of Health include not only employees of NHS divisions but also local authority social services workers.[10] The full-time equivalent figure for 2005 was about 980,000 staff.[9]

The NHS also plays a unique role in the training of new doctors in the British Isles, with approximately 8000 places for student doctors each year, all of which are attached to an NHS University Hospital trust. After completing medical school these new doctors must go on to complete a two year foundation training programme to become fully registerred with the General Medical Council. Most go on to complete their foundation training years in an NHS hospital although some may opt for alternative employers such the armed forces [11].

Most staff working for the NHS in England and Wales, including non-clinical staff and GPs (most of whom are self-employed) are eligible to join the NHS Pension Scheme which, from 1 April 2008, is an average-salary defined benefit scheme.

The total budget of Department of Health in England in 2008/9 was £94bn of which NHS England accounted for £92.5bn (exceeding several national government budgets).[12] The National Audit Office reports annually on the summarised consolidated accounts of the NHS [13].

The principal fundholders in the NHS system are the NHS Primary Care Trusts (PCTs), who commission healthcare from hospitals, GPs and others. PCTs disburse funds to them on an agreed tariff or contract basis, on guidelines set out by the Department of Health. The PCTs receive a budget from the Department of Health on a formula basis relating to population and specific local needs. They are required to "break even" - that is, they must not show a deficit on their budgets at the end of the financial year, although in recent years cost and demand pressures have made this objective impossible for some Trusts. Failure to meet financial objectives can result in the dismissal and replacement of a Trust's Board of Directors, although such dismissals are enormously expensive for the NHS[14].

Except for set charges applying to most adults for prescriptions, optician services and dentistry, the NHS is free for all patients "ordinarily resident" in the UK at the point of use irrespective of whether any National Insurance contributions have been paid.

Those who are not "ordinarily resident" (including British citizens who have paid National Insurance contributions in the past) are liable to charges for services other than that given in Accident and Emergency departments or "walk-in" centres.

NHS costs are met, via the PCTs, from UK government taxation, thus all UK taxpayers contribute to its funding.

Exemption for missionaries who work abroad for a UK based organisationEdit

In England, from 15 January 2007, anyone who is working outside the UK as a missionary for an organisation with its principal place of business in the UK will be fully exempt from NHS charges for services that would normally be provided free of charge to those resident in the UK. This is regardless of whether they derive a salary or wage from the organisation, or receive any type of funding or assistance from the organisation for the purposes of working overseas. This is in recognition of the fact that most missionaries would be unable to afford private health care and those working in developing countries should not effectively be penalised for their contribution to development/other work.

As of April 2008 the prescription charge for medicines is set at £7.10 (which contrasts with Northern Ireland at £6.85, Scotland at £5 and Wales where they are free.) People over sixty, children under sixteen (or under nineteen if the child is still in full time education), patients with certain medical conditions, and those with low incomes, are exempt from paying. Those who require repeated prescriptions may purchase a single-charge pre-payment certificate which allows unlimited prescriptions during the period of validity. The charge is the same regardless of the actual cost of the medicine but higher charges apply to medical appliances. For more details of prescription charges, see Prescription drugs.

However, the rising costs of some medicines, especially some types of cancer treatment, means that prescriptions can present a heavy burden to the PCTs whose limited budgets include responsibility for the difference between medicine costs and the fixed prescription charge. This has led to disputes in certain cases (e.g. over Herceptin), as to whether such drugs should be prescribed.[15]

Following the government's introduction of a new contract in April 2006, NHS dentistry is not as widely available as it once was[16], with 900,000 fewer patients seeing an NHS dentist in 2008 and 300,000 losing their NHS dentist in a single month[17]. This has forced many patients to pay much higher sums for private treatment[18], and has been criticised by the British Dental Association as having "failed to improve access to care for patients and failed to allow dentists to provide the modern, preventive care they want to deliver"[17].

Where available, NHS dentistry charges from 1 April 2008 are: £16.20 for an examination; £44.60 if a filling is needed; and £198 for more complex procedures such as crowns, dentures or bridges.[19]. About 50% of the income of dentists comes from work sub-contracted from the NHS.[20]

Please expand this article.This template may be found on the article's talk page, where there may be further information. Alternatively, more information might be found at Requests for expansion.Please remove this message once the article has been expanded.

From 1 April 2007 the NHS Sight Test Fee (in England) is £19.32; in 2006-7 there were 13.1 million NHS sight tests carried out in the UK.
A voucher system is employed to offset private commitments towards eyeware appliances. Currently £35.50 for the most common 'A' voucher.

Since January 2007, the NHS have been able to claim back the cost of treatment, and for ambulance services, for those who have been paid personal injury compensation.[21] Prior to 2007, the NHS were only able to claim back their costs for those who received personal injury compensation as a result of a motor vehicle crash.[22] In the last year of the old scheme, over £128 million was reclaimed.[23]

Car parking charges are an important source of revenue for the NHS, [24] with some hospitals deriving more than 1 per cent of their budget from them.[25] The level of fees is controlled individually by each trust.[24] In 2006, car park fees contributed £78 million towards hospital budgets, with individual hospitals netting up to £1.5 million.[24][25] Patient groups are opposed to such charges.[24] (This contrasts with Scotland where car park charges are due to be almost entirely scrapped by the end of 2008[26] and with Wales where car park charges are due to be scrapped by the end of 2011.)[27]

There are over 300 official NHS charities in England and Wales. Collectively, they hold assets in excess of £2bn and have an annual income in excess of £300m. [28] .Some NHS charities have their own independent board of Trustees whilst in other cases the relevant NHS Trust acts as a corporate Trustee. Charitable funds are typically used for medical research, larger items of medical equipment, aesthetic and environmental improvements, or services which increase patient comfort.

In addition to official NHS charities, many other charities raise funds which are spent through the NHS, particularly in connection with medical research and capital appeals.

As each division of the NHS is required to break even at the financial year-end, the service should in theory never be in deficit. However in recent years overspends have meant that, on a 'going-concern' (normal trading) basis, these conditions have been consistently, and increasingly, breached. Former Secretary of State for HealthPatricia Hewitt consistently asserted that the NHS will be in balance at the end of the financial year 2007-8;[29] however, a study by Professor Nick Bosanquet for the Reform think tank predicts a true annual deficit of nearly £7bn in 2010.[30]

The 1980s saw the introduction of modern management processes (General Management) in the NHS to replace the previous system of consensus management. This was outlined in the Griffiths Report of 1983.[31]
This recommended the appointment of general managers in the NHS with whom responsibility should lie. The report also recommended that clinicians be better involved in management. Financial pressures continued to place strain on the NHS. In 1987, an additional £101 million was provided by the government to the NHS. In 1988 the then Prime Minister, Margaret Thatcher, announced a review of the NHS. From this review and in 1989, two white papersWorking for Patients and Caring for People were produced. These outlined the introduction of what was termed the "internal market", which was to shape the structure and organisation of health services for most of the next decade.

In 1990, the National Health Service & Community Care Act (in England) defined this "internal market", whereby Health Authorities ceased to run hospitals but "purchased" care from their own or other authorities' hospitals. Certain GPs became "fund holders" and were able to purchase care for their patients. The "providers" became independent trusts, which encouraged competition but also increased local differences. There is also evidence that increasing competition decreased the quality of patient care, with death rates highest in those areas forced to compete for patients.[32]

These innovations, especially the "fund holder" option, were condemned at the time by the Labour Party. Opposition to what was claimed to be the Conservative intention to privatise the NHS became a major feature of Labour's election campaigns.

Labour came to power in 1997 with the promise to remove the "internal market" and abolish fundholding. In a speech given by the new Prime Minister, Tony Blair, at the Lonsdale Medical Centre on 9th December 1997, he stated that:

"The White Paper we are publishing today marks a turning point for the NHS. It replaces the internal market with "integrated care". We will put doctors and nurses in the driving seat. The result will be that £1 billion of unnecessary red tape will be saved and the money put into frontline patient care. For the first time the need to ensure that high quality care is spread throughout the service will be taken seriously. National standards of care will be guaranteed. There will be easier and swifter access to the NHS when you need it. Our approach combines efficiency and quality with a belief in fairness and partnership. Comparing not competing will drive efficiency."[33]

However in his second term Blair renounced this direction. He pursued measures to strengthen the internal market as part of his plan to "modernise" the NHS.

Driving these reforms have been a number of factors. They include the rising costs of medical technology and medicines, the desire to improve standards and "patient choice", an ageing population, and a desire to contain government expenditure. (Since the National Health Services in Wales, Scotland and Northern Ireland are not controlled by the UK government, these reforms have increased the differences between the National Health Services in different parts of the United Kingdom. See NHS Wales and NHS Scotland for descriptions of their developments).

Reforms have included (amongst other actions) the laying down of detailed service standards, strict financial budgeting, revised job specifications, reintroduction of "fundholding" (under the description "practice-based commissioning"), closure of surplus facilities and emphasis on rigorous clinical and corporate governance. In addition medical training has undergone an unsuccessful restructuring which was so badly managed that the Secretary of State for Health was forced to apologise publicly. MMC is now being revised but its flawed implementation has left the NHS with significant medical staffing problems which are unlikely to be resolved before 2010. Some new services have been developed to help manage demand, including NHS Direct. A new emphasis has been given to staff reforms, with the Agenda for Change agreement providing harmonised pay and career progression. These changes have, however, given rise to controversy within the medical professions, the media and the public.

The Blair Government, whilst leaving services free at point of use, has encouraged outsourcing of medical services and support to the private sector. Under the Private Finance Initiative, an increasing number of hospitals have been built (or rebuilt) by private sector consortia; hospitals may have both medical services (such as "surgicentres"),[34] and non-medical services (such as catering) provided under long-term contracts by the private sector. A study by a consultancy company which works for the Department of Health shows that every £200 million spent on privately financed hospitals will result in the loss of 1000 doctors and nurses. The first PFI hospitals contain some 28 per cent fewer beds than the ones they replaced.[35]

In 2005, surgicentres (ISTCs) treated around 3% of NHS patients (in England) having routine surgery. By 2008 this is expected to be around 10%.[36]NHS Primary Care Trusts have been given the target of sourcing at least 15% of primary care from the private or voluntary sectors over the medium term.

As a corollary to these intitiatives, the NHS has been required to take on pro-active socially "directive" policies, for example, in respect of smoking and obesity.

The NHS has also encountered significant problems with the IT innovations accompanying the Blair reforms. The NHS's National Programme for IT (NPfIT), believed to be the largest IT project in the world, is running significantly behind schedule and above budget, with friction between the Government and the programme contractors. Originally budgeted at £2.3 billion, present estimates are £20-30 billion and rising.[37] There has also been criticism of a lack of patient information security.[38] The ability to deliver integrated high quality services will require care professionals to use sensitive medical data. This must be controlled and in the NPfIT model it is, sometimes too tightly to allow the best care to be delivered. One concern is that GPs and hospital doctors have given the project a lukewarm reception, citing a lack of consultation and complexity.[39] Key "front-end" parts of the programme include Choose and Book, intended to assist patient choice of location for treatment, which has missed numerous deadlines for going "live", substantially overrun its original budget, and is still (May 2006) available in only a few locations. The programme to computerise all NHS patient records is also experiencing great difficulties. Furthermore there are unresolved financial and managerial issues on training NHS staff to introduce and maintain these systems once they are operative.

From 1st April, 2008, everyone over 40 in England will be offered health checks for heart disease, stroke, diabetes and kidney disease under new government plans. However, doctors are not convinced that the policy will be effective. [40]

Treatments determined by NICE to be ineffective (e.g. homeopathy) or relatively cost-ineffective (i.e. drugs that have only minor effect at great cost) are simply not offered by the NHS though may be available privately. These controls have been labelled "rationing" [41] though others argue that these are a sensible cost-control mechanism to fund only cost-effective[42]evidence-based medicine although this argument is controversial as many drugs with proven efficacy (e.g. anticholinesterase for Alzheimer's Disease[43], [44]) are not fully funded.

In the NHS, GP referrals are needed to access specialist care and one of the original roles of general practitioner was to act as 'the gatekeeper'. This role as gatekeeper has become more prominent in the 1990s with the introduction of the 'internal market' with GPs managing funds to buy clinical services. In 2000s, the role of gatekeeper has been increasingly moved to primary care trusts (PCTs) that issue guidelines to limit referrals to secondary care. 'Referral management centres' are also another recent innovation to divert referrals from GPs to cheaper nursing or therapy-led alternatives.

It has been argued that a nominal charge for an appointment with a GP could be introduced to prevent patients consulting their GP for frivolous reasons [45]. To date, this has never been introduced to avoid the danger of patients avoiding consultations (for financial reasons) for conditions which might be potentially serious.

Over time, increased demand leads to continual political pressures to increase spending and widen the range of treatments available.

Supporters of the NHS would point out that the NHS has wide public support and the English population has as good a health outcome as many other similar countries, and often at much lower cost. Political pressure could work both ways, but the Blair government was elected in 1997 largely on a promise to invest more taxpayers money in health to bring spending closer to the European average. Most people[How to reference and link to summary or text] would prefer to see gradual improvements within the current framework and be able to hold politicians to account for the service. This is the position of all the major political parties, none of which has an agenda to replace or make a wholesale reform to the system. The Conservative Party says its policies are aimed at "Protecting and improving our health service by putting patients back at the heart of the NHS, and trusting the professionals to ensure that they are able to use their skills to make the fullest possible contribution to patient care."[46].

Taxpayers who choose to pay for private healthcare must nonetheless still contribute to the NHS via taxation, and in effect "pay twice", although the vast majority of emergency medical treatment is carried out by the NHS. This is not an effect specific to the NHS, and occurs whenever a choice between a publicly-funded and privately-funded service exists - for instance in private education.

Some patients with complex illnesses pay for some medical services privately, while turning to the NHS for the rest of their care. In one recent case a cancer patient was told that if she paid privately for a drug that was not covered by the NHS she would have to pay for the rest of her care. NHS officials argue that allowing the practice would give wealthy patients an unfair advantage and undermine the philosophy of the system.[47]

Rationing is a part of all health care systems because resources are necessarily finite. In purely private systems, health care is rationed via the price mechanism, with those being able to or wanting to pay for care getting it immediately and those not able waiting indefinitely (until they can afford it, which may be never). In the NHS, which aims to give a broad coverage of care to all without charging, health care is rationed on the grounds of clinical need, meaning that emergency cases (e.g. heart attacks) get instant access where those with less urgent needs (e.g. cataract surgery) are given lower priority and so wait longer.

Although there are obvious arguments in favour of prioritising by clinical need rather than ability to pay[48], it can mean that waiting lists vary widely between regions. Patients waiting can choose to have a procedure done outside their local NHS district in order to be seen more quickly, and if the waiting time is long can often get private treatment at public expense, either in the UK or abroad. A major programme is underway in the NHS to reduce all wait times to 18 weeks by December 2008[49]. This new target starts at the point the time the patient's own doctor writes to the hospital specialist and ends when treatment begins. It therefore includes the time to make the first appointment, and the time for all diagnostic tests to be completed, evaluated, and discussed with the patient, which were not in the previous target. It has been widely criticised by doctors, healthcare professionals, and think-tanks as diverting resources from more serious conditions to achieve politically-motivated goals[50], and doubts persist over its achievability[51].

The term bed-blockers is often used to refer to patients still receiving care, even though their acute ailment has been treated and they are fit for discharge. This strains hospital resources, through both increased costs and longer waiting times for other patients. In the UK, bed-blockers are frequently geriatric patients awaiting a placement in a nursing or residential facility.[52][53]

Both C. difficile and MRSA are, however, not exclusive to the NHS, existing in British private hospitals and throughout other western healthcare systems; for instance, cases doubled in the USA's private healthcare system between 1999 and 2005[55], and the UK's death rate is half that of the USA's[56]. The introduction of Private Finance Initiative cleaning contractors into the NHS and the associated "cutting corners on cleaning"[57] have been blamed for the problem, as has increased drug resistance due to inappropriate prescribing of antibiotics and patients failing to complete courses of antibiotics.

Another viewpoint is that the spread of communicable diseases in hospitals is facilitated by the overcrowding in NHS hospitals with high bed occupancy rates (as the NHS has a low bed:population ratio produced by hospital bed closures and the increasing emphasis on increasing bed 'turnaround time')[58].

The NHS has been criticised over the implementation of its National Programme for IT which is designed to provide the infrastructure for electronic prescribing, booking appointments and elective surgery, and a national care records service. The programme has run into delays and overspends, with the initial budget of £2.3 billion over three years officially revised to £12.4bn over 10 years[59] and some sources putting it as high as £20bn[60]. Critics including the House of Commons Public Accounts Committee and the National Audit Office claim the project is falling behind schedule[61][62]. In addition, 93% of doctors within the NHS are not confident their patients' data will be secure[63], some GP practices have begun to advise all their patients to opt-out of the scheme[64], and privacy campaigners have claimed the national care records system breaches patients' privacy rights[65].

There has been a decreasing availability of NHS dentistry following the new government contract[16] and a trend towards dentists accepting private patients only[66], with 10% of dentists having rejected the contract offered[67].

The lack of availability of some treatments due to their perceived poor cost-effectiveness sometimes leads to what some call a "postcode lottery".[68]

NHS supporters would argue that the NHS has a duty to ensure that taxpayers money is used wisely and such denials are effective controls. People can always choose to go private, if they can afford it, if the treatment is legally available in the UK or elsewhere.[How to reference and link to summary or text]

Supporters would argue that there is nothing endemic about such issues which might equally have occurred in other types of health care establishments. They might also point out that the detection of such issues leads to better controls being established throughout the NHS for the benefit of all.

An October 14, 2008 article in The Daily Telegraph stated, "An NHS trust has spent more than £12,000 on private treatment for hospital staff because its own waiting times are too long." [70]

With respect to assessing, maintaining and improving the quality of healthcare, in common with the United States and many other developed countries, the UK government has separated the roles of suppliers of healthcare and assessors of the quality of its delivery. Quality is assessed by independent bodies such as the Healthcare Commission according to standards set by the Department of Health and the National Institute for Health and Clinical Excellence. Responsibility for assessing quality will transfer to the Care Quality Commission from April 2009.

The ambulances used by the NHS are sometimes referred to by their staff as the "Big White Taxi Service". This slang term is used to express the frustration felt when members of the public dial 999 for minor ailments and injuries.[71] The term is becoming obsolete as ambulances are no longer painted white and the term "Blue Light Taxi" is now more widely used.

Allyson M Pollock (2004), NHS plc: the privatisation of our healthcare. Verso. ISBN 1-84467-539-4 (Polemic against PFI and other new finance initiatives in the NHS)

Rudolf Klein (2006), The New Politics of the NHS: From creation to reinvention. Radcliffe Publishing ISBN 1 84619 066 5 ( Authoritative analysis of policy making (political not clinical)in the NHS from its birth to the end of 2006)

Geoffrey Rivett (1998) From Cradle to Grave, 50 years of the NHS. Kings Fund, 1998, Covers both clinical developments in the 50 years and financial/political/organisational ones. kept up to date at www.nhshistory.net